Editor's Memo
by Forest A. Tennant, MD, DrPH
 At home, self-administered opioids
including meperidine, morphine, and hydromorphone among others have been a standard in
medical practice for decades. Countless patients who experience disabling, episodic bouts
of severe pain from such diseases as migraine headaches, pancreatitis, sickle cell,
porphyria, and even spine degeneration — and who are taught self-administration of
injectable opioids — have been able to avoid trips to an emergency room or suffering
days in bed with this practice.
Pain patients in rural areas have often had little option but to self-administer
injectable opioids. Even patients in an urban area may not be able to reach a hospital
emergency room in a rapid manner and require self-administered injections. Some patients
with severe intractable pain have found that self-administered opioid injections have been
their only effective pain control measure. Although uncommon, pain specialists will
encounter patients who report that injectable morphine, meperidine, or hydromorphone is
the only medication that effectively relieves pain. Meperidine is particularly worrisome
because chronic administration by injections may produce seizures and abscess formation
that may lead to osteomyelitis and severe tissue destruction. Some patients, however, have
been able to use injectable meperidine and other opioids for many years with no seizure or
adverse effects.
No physician wants to see a pain patient resort to self-administered opioid injections
for pain control and they invariably reserve injections as a “last resort.” But
an ugly development has occurred. Some institutions and physicians are now declaring
meperidine too “dangerous” to even be on formularies and they may even condemn
physicians who prescribe meperidine as well as any other injectable opioid. Indeed,
physicians should attempt a variety of the new commercially available opioid formulations
such as suppositories, concentrated oral liquids and transmucosol fentanyl before
resorting to injections.
However, some patients initiated opioid injections years ago when physicians had few
alternatives in their armamentarium. To discontinue injectable opioids in these patients,
particularly when there is good pain control with few or no complications, borders on
cruelty and will likely invoke needless suffering. A recent really ugly development has
been the declaration by some insurance companies and HMOs that self-administered opioid
injections should not be a covered benefit because they are too “dangerous.”
This twist doesn't, however, seem to apply to self-administered insulin injections. In
actuality, a patient tolerant to opioids can very safely self-administer oral and
injectable opioids. Also, patients in pain appear to neutralize the respiratory effects of
opioids. Common sense does prevail once in a while. This editor is aware of a recent case
in California where the state's HMO watchdog oversight agency required an insurance
company to pay for injectable hydromorphone in a case of a woman who suffered intractable,
severe headaches that began during the delivery of her child.
Just why opioid injections may relieve pain when other formulations fail is uncertain
and this question should be a subject of academic pursuit. Malabsorption of opioids is
common in severely ill patients and others may have genetic, metabolic abnormalities of
opioid deactivation that mandates an injection that bypasses the liver and rapidly reaches
the central nervous system. A practical approach to opioid self-injections seems evident.
Keep every opioid on formularies. Sooner or later some physician and some patient will
find it's all that “works.” Try new opioid formulations before resorting to
injections, but if the patient has been successfully using injections for years, why force
suffering by demanding cessation of an effective treatment due to a bias against
injections. After all, severe pain will shorten life enough without physician assistance.
— Forest A. Tennant, MD, DrPH
Editor in Chief
— Jul/Aug 2004
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